Bangladesh: Broaden Outreach to Increase Use of New Services
OR Summary no. 39 (PDF)

Background

Photo credit: FRONTIERS/Bangladesh

In 1997 the government of Bangladesh adopted a plan to shift from home-based family planning services to an approach in which family planning and other reproductive health services are integrated with clinic-based primary health care. The plan called for a wider range of reproductive health services provided as part of an “essential services package” (ESP).  Also in 1997, the U.S. Agency for International Development (USAID) launched a program supporting nongovernmental organizations (NGOs) enacting the ESP approach.  The NGO program is designed to both improve quality of care and increase cost recovery for services. Under the previous strategy, health workers delivered free or low-cost family planning services through door-to-door visits. This allowed women to stay at home in compliance with the tradition of purdah or seclusion of women. The ESP approach imposes new costs on women and their families, in that women must both leave home and pay for family planning and reproductive health services.

In 1999 John Snow Inc., with assistance from FRONTIERS, undertook a qualitative study in sites where NGOs are implementing the ESP policy. The study assessed clients’ acceptance of the new service delivery strategy, the effect of the policy change on demand for family planning services, and clients’ ability and willingness to pay for services. The research took place over a period of six months in two rural sites where NGOs had replaced the door-to-door services with the clinic-based ESP approach. Data were gathered through interviews (249 women and 72 men), focus group discussions (nine with women and one with men), and review of service records. The interview participants included clients and staff of NGO clinics, former door-to-door workers, providers, community members, and special groups including non-users of family planning and working women. 

Findings

• Women are strongly committed to family planning. Concerns that demand for family planning would decline once clients had to leave home or pay to obtain methods were proven unfounded in the study sites. Most women were determined to maintain their supply of methods when the new strategy was implemented. Norms related to purdah by and large did not keep women from leaving home to obtain services.
  
• Men were instrumental in sustaining family planning use. Interviews showed that men frequently helped their wives obtain contraceptives when door-to-door services were not available.  The main barriers to men’s increased participation in reproductive health care were “shyness” and a reluctance to pay for women’s health care costs, not opposition to family planning.
  
   

  “Now many men bring methods for their wives. Before women did not
  have to talk about these matters with men as much. Now men also
  appreciate the need to have fewer children.”

  —Female family planning client

   

• Most clients found service charges reasonable. However, payment options at the NGO clinics could be clarified. Of 112 clients interviewed, 65 needed either credit or a subsidy; yet many clients and some providers were unaware that such options were available.  Many women also expected NGO services to be free, either because neighboring areas served by government providers offered free services, or because the NGO and government services were indistinguishable to the community.
  
• Clients valued the improved quality of care and comprehensive reproductive health services offered at the NGO clinics. They expressed particular appreciation for providers’ respectful behavior, the equal treatment of rich and poor clients, and the clean and uncrowded clinic settings. Women especially appreciated that providers did not pressure them to accept specific services or methods.
  
• The NGO clinics had mixed success in clearly establishing their role as providers of comprehensive basic services. Some clients still overwhelmingly associated the NGOs with family planning and some viewed the NGO providers as less experienced or capable because they refer more complex cases to specialists.

Policy Implications

• The ESP approach requires changing a longstanding service delivery culture. The widespread perception that family planning services are offered as part of a national fertility reduction agenda—which may foster distrust and confusion—presented a challenge to the NGOs as they tried to implement a sustainable, client-centered essential services model.  
  
• Programs need to improve communication to the public about policy changes in service delivery systems that affect them, such as fees and referrals.
  
• Managers should consider ways to adapt services to include men and accommodate their needs. Men’s involvement will help sustain the strong demand for reproductive health services.

January 2004

Source: Bates, Lisa, Md Khairul Islam, Sidney Ruth Schuler, and Md Alauddin. 2000. "From the home to the clinic: The next chapter in Bangladesh's family planning success story—Rural sites," FRONTIERS Final Report. Washington, DC: Population Council. (PDF, 620 KB)

This project was conducted with support from the U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT under Cooperative Agreement Number HRN-A-00-98-00012-00.